The current study was conducted in the hope of generating university-specific information regarding health literacy among college students. The authors conducted this research among college students for different reasons. Most importantly, the literature regarding health literacy, measured by the HLQ, in this population is scarce. College students spend a significant amount of time in a stressful environment, and they are at high risk for engaging in unhealthy behaviors. Having an adequate level of health literacy can help college students make appropriate decisions about their health. On the other hand, making inappropriate decisions and engaging in unhealthy behaviors, such as unhealthy eating [
34] and getting less than the recommended amount of physical activity [
35], negatively impacts academic achievement. The long-term effect of such health problems is detrimental as they increase the risk for life-threatening, chronic problems such as cardiovascular disease [
36], metabolic syndrome [
37], and mental health problems [
38]. Therefore, understanding the health needs of young adults, through studying health literacy, is at the core of promoting health and preventing future diseases. The following subsections will address the interpretation of the current results within the context of the literature.
Mean differences based on demographic characteristics
The MANOVA results showed that age, gender, smoking status, year of study, and field of study all affect the linear composite of the dependent variables (HLQ scales) in college students. Based on the results of the univariate and follow-up analyses, age did not have any detected effect on the level of health literacy. There is evidence in the literature about the effect of age on health literacy among college students, measured using S-TOFHLA [
18]. However, administering the HLQ to college students revealed similar results to those reported in this study, with a significant effect of age only on the “Appraisal of health information” scale [
24]. Similarly, age had a weak, positive correlation with the same scale of the HLQ in a study conducted in Denmark [
25]. The effect of another related factor, year of study, revealed differences in the levels of some HLQ scales. Of most importance, the results showed that first-, second-, and third-year students had lower levels of health literacy in the following scales: “Feeling understood and supported by healthcare providers”, “Appraisal of health information”, and “Understand health information”. This finding is consistent with the findings reported by other studies conducted using the HLQ [
26] and the Adult Literacy Scale [
27]. Further investigation is needed to explore how health literacy is affected by the year of study.
Regarding gender, the related literature provides mixed evidence regarding the relationship between college students’ gender and health literacy. The findings of this study showed that female students had higher levels of health literacy than males in the following areas: “Social support for health”, “Navigating the healthcare system”, “Ability to find good health information”, and “Understand health information” (Table
5). This is congruent with previous research findings for a study conducted among college students in Texas [
24]. In contrast, a study conducted in China showed that male students had higher levels of health literacy than females [
26]. Another study revealed no gender difference except for the “Social support for health” scale of the HLQ [
25]. Such discrepancies could be attributed to different factors, including the variations in the educational systems and the sociocultural characteristics of college students [
25]. Another possible explanation of the variation could be linked to the existing differences between the target populations. Whereas the target population of the current study was all college students (health-related and others), other studies targeted only health-related college students [
25,
26]. Despite these mixed findings, gender should be considered a source of health literacy disparity in college students. This could be useful for creating customized programs for improving health literacy among college students.
Our results suggest that college students’ smoking status is a significant determinant of health literacy. Compared to smokers, nonsmokers had a higher level of health literacy on seven out of the nine scales of the HLQ. A recent study addressed the importance of studying campus tobacco culture in determining health literacy among college students [
39]. According to the Healthy Campus 2020 [
40], a campus-wide healthy environment is enhanced by adopting an ecological approach that focuses on both community and individual determining factors of health. Creating and/or activating smoking-free policies is paramount. Moreover, understanding the health needs of college students who smoke, as reported in this study, provides invaluable information to build a healthy campus.
Many research studies report the overall level of education as a predictor of health literacy [
28,
30,
41]. In this study, we intended to investigate a usually overlooked area: the effect of students’ fields of study on health literacy. The field of study, health-related vs. others, significantly affected all scales of the HLQ. Those in the health-related faculties averaged significantly higher scores than students from other faculties on all scales. College classification was reported as a significant predictor of college students’ health literacy [
18]. The number of health education topics studied by college students was found in previous research to be positively correlated with the level of health literacy [
21]. Elsborg and colleagues found that public health students had higher scores on the HLQ scales than students from other health-related faculties [
25]. These findings are, however, inconsistent with the findings reported by Zhang et al., who found that engineering students had higher scores on HLQ scales [
26]. Both the levels of significance and the calculated effect sizes reported in this study indicate a disparity that should be considered in studying health literacy in college students. The potential implications of this particular area are discussed in the following section.
The multidimensional nature of health literacy necessitates collaboration of efforts and utilization of the best available evidence about how it impacts health. However, evidence from the literature shows that health literacy is still an under-investigated phenomenon, especially outside the U.S. The larger study we are currently working on aims to improve the health promotion of college students and staff. Encouraging young populations, such as college students, to live a healthy lifestyle requires in-depth understanding of their health needs to build suitable health promotion interventions. In addition, a successful health promotion program is one that incorporates individual- and community-based information to create a healthy environment [
40]. The results of this study highlight the disparities in health literacy as evidenced by variations based on the students’ age, gender, smoking status, year of study, and field of study. These results can be used to guide future investigations of the most effective intervention programs to enhance students’ health literacy and overall health.
A prominent finding of the current study is the lower level of health literacy in students from non-health-related faculties. Those students have apparent weaknesses in all dimensions of health literacy. The WHO’s publication
Framework for Action on Interprofessional Education & Collaborative Practice calls for action to achieve better health through investing in interprofessional education [
42]. Interprofessional education takes place when students from two or more fields learn about, with, and from each other [
42]. Utilizing the resources available in educational institutions, health educators are encouraged to collaborate and create mandatory/elective courses and make them available to students from both health-related and non-health-related faculties. Such courses should be created considering the health needs of college students. Innovation in education through integrating evidence-based information with creative teaching strategies, such as project- and problem-based learning, seems promising. As the students work and learn together and from each other, the health outcomes will most likely be improved [
42]. Additionally, the role of students from non-health-related faculties in disseminating educational and health outcomes is pivotal.
Limitations
Despite the limitation of relying on self-report measures, combining the data from the demographics questionnaire with the HLQ provided a broader range of information regarding college students’ health literacy. We tried to strengthen our research by obtaining and integrating data regarding the anthropometric measurements from college students. Our intention was to measure such fundamental parameters as weight, height, and skinfold. However, that could not be accomplished during the current phase of enrollment in the larger study due to an inability to secure an appropriate, private space to take these measurements. Our intention is to gather such data and integrate it into future research about health literacy and promotion. Regarding the sample, we employed two essential criteria during the recruitment of participants, as discussed earlier, to enhance the representativeness of the study sample for the overall university population. However, some groups were not equivalent, for example, the year of study (fifth-sixth year) and smoking status, which could impact the generalizability of the findings. The small number of international students who participated in this study raises concerns about the generalizability of our findings to this group of college students. In addition, using a nonprobability sampling method, purposive sampling, could limit the generalizability of the findings.